The culture of the NHS, and the incentives that make staff act against their
better judgement, need to change if there is to be no repeat of the Mid
Staffs scandal, argues Roger Taylor.

A dog shelter in New Zealand recently made headlines by training some of its dogs to drive cars prompting delighted applause from YouTube viewers worldwide. Psychologists pointed out that the praise ought to go the trainers, not the dogs. It was, they said, nothing more than an example of “operant conditioning” - the phrase psychologists use to describe the way in which animals can be made to do things utterly contrary to their nature by rewarding certain behaviours and punishing others.

It is important to bear this in mind in trying to understand what happened in Mid Staffordshire NHS Foundation Trust during the middle years of the last decade when standards of care fell so low that the treatment meted out to some patients was at times cruel.

A lot of people have asked, ‘How could people employed to care for the sick have behaved as they did?” In the case of some, that is the right question.

But for most, the question is rather different: for most the question is: ‘How did we create a health service that could induce decent people to do things so thoroughly against their better nature?”

Reading the stories about the infamous Wards 10 and 11 it is clear that unconscionable behaviour had somehow become routine. Patients were humiliated, mistreated and in some cases lost their lives unnecessarily. Doctors, nurses and NHS managers have all accepted that the service provided was unacceptable, yet somehow no-one was able to stop it.

Related Articles

The Francis Inquiry which is due to report on Wednesday will talk about the culture of the NHS and how it needs to change. But in what way does the culture of the NHS allow this to happen? To answer that we need to understand the incentives – the rewards and the punishments - that shape the behaviour of NHS organisations.

What happens when a hospital like Mid-Staffordshire finds it is struggling to deliver a high quality service with the resources available? As an NHS chief executive in that situation, you could simply overspend and breach your targets – and quite likely lose your job. You could try to argue to re-organise services but you are likely to face considerable opposition from both clinicians and the public. Or you can just cut costs, cross your fingers and and hope that no-one notices if the standards of care deteriorate.

The frightening truth about the NHS is that the third of those options is the one that every incentive in the system is pushing you towards. Because the risks that a poor quality service will get identified quickly and the risks of that having consequences for your career remain troublingly remote.

Dr Foster has been publishing data on mortality for all hospital in England since 2001. From the start Mid-Staffordshire had higher than expected mortality rates. In 2007, the data showed the trust had amongst the highest rates in the country. It was mortality analyses from Dr Foster that first triggered the Healthcare Commission, the regulator at the time, to start investigating the hospital. So why did they not prompt a similar reaction from the hospital board or the local NHS?

I was asked to testify to the Mid-Staffordshire inquiry to try to explain this mystery.

It was not that these organisations failed to take any action. They commissioned studies into statistical methodology. They conducted investigations into data quality. They changed the records to make the figures look better. They took plenty of action. The only thing they did not do was uncover the problems with the care being given to patients.

After the problems at Mid Staffordshire first came to light, the Department of Health set up a group of experts to try to fix the problem. The question we were asked was: what is the right way to interpret and respond to mortality figures? After much debate, we concluded that mortality data should act as a prompt to ask further questions.

What? Is that it? But wasn’t that exactly what the problem was in the first place? That instead of acting on the data the hospital simply asked more and more questions.

Actually, this is the right answer. Complex data such as outcome measures require careful interpretation. They should act as spur to ask more questions. But this will only work if the people asking them are competent to judge when they are getting the right answers and have a desire to know the truth. .

In December the Dr Foster Hospital Guide named 12 NHS trusts with worryingly high mortality and just last week the NHS named five trusts - many of them the same a- as having consistently high death dates. The response from many commentators was, as always, that care needs to be taken in interpreting the figures. That is true. But who is actually doing that? Who is carefully interpreting the figures and coming to a reliable assessment of quality.

We have regulators, commissioners, health authorities, oversight committees and a host of other interested parties. But if you ask where in this panoply is there someone who can reliable recognise quality and its opposite, or where, in all the myriad information published about NHS services, there is anyone making a credible assessment about whether a service is superb, just about up to scratch, or simply no good; the answer is nowhere.

This is a vacuum that needs to be filled as a result of this inquiry.The NHS needs to move away from its blame culture in which performance is assessed on the basis of report cards and targets. It needs to develop a culture in which quality is assessed with skill and judgment.

Much of the response to Mid-Staffordshire has focused on improving the available data about standards. This is entirely welcome. The NHS Commissioning Board is now starting to replace the old targets with measures of the outcomes of care and the experience of patients. But these changes on their own are not enough. These new data are complex and require interpretation.

The NHS is getting better a producing information about quality. But its ability to interpret it lags far behind. For too much of the time, work by NHS organisations to understand the quality of services is too much like a dog driving a car. It looks impressive but we all know, in truth, it is not the real thing.

If the NHS is to prevent another Mid-Staffs, front line staff must work in organisation that can recognise and reward quality care. The managers and boards of these organisations must, in turn, be held to account by commissioners and regulators who have the skills to spot failing services and acknowledge those that excel.

Doctors, nurses and NHS managers come into their professions wanting to ensure that patients are treated and looked after as well as they can be. Where they fail it is all too often they have been incentivised to act against their better instincts and been managed by organisations that are blind to the differences that matter.